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health assess > HEENT, Throat, Regional Lymphatics > Flashcards

HEENT, Throat, Regional Lymphatics Flashcards

1
Q

_____ & _____ (__________) are ideal places to check facial features for symmetry

A
  • nasolabial folds
  • palpebral fissures (opening btw eyelids)
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2
Q

cranial nerve 5

A
  • trigeminal
  • responsible for sensation in face & motor fxns like biting and chewing
  • largest of cranial nerves
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3
Q

cranial nerve 7

A
  • facial nerve
  • facial expression
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4
Q

sutures

A

closed cavity on the skull

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5
Q

parotid glands are located where?

A

just below and in front of each ear

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6
Q

2 other pairs of major salivary glands

A
  • sublingual (under tongue)
  • submandibular (under jaw)
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7
Q

what does your parotid gland connect to?

A
  • Stensen’s duct (tube)
  • carries saliva to mouth, release it near upper molar teeth
  • sialolithiasis-calcified stones (calculi)
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8
Q

trigeminal neuralgia

A

intermittent sharp shooting facial pain lasting several mins over divisions of the 5th trigeminal cranial

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9
Q

what ages make a headache is worrisome?

A
  • child < 5
  • adults > 50
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10
Q

what type of headache is indicative of meningitis?

A

headache that moves into the neck, causing neck pain w/ head flexion

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11
Q

a typical migraine headache has?

A
  • prodromal symptoms
  • visual disturbances, vertigo, tinnitus, and/or numbness or tingling of fingers + toes
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12
Q

what is indicative of a migraine headache?

A

throbbing severe pain on one side of head, along w/ ringing in ears prior to headache

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13
Q

what headache is an early sign of increased intracranial pressure (ex: brain tumor)?

A

morning headaches that subside after rising

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14
Q

cluster headaches

A
  • typically localized in eye + orbit
  • radiate to facial + temporal regions
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15
Q

what characteristics to ask about headaches?

A
  • dizziness?
  • light-headedness?
  • spinning?
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16
Q

what to ask for history in HEENT associated w/ headaches

A
  • head injury (when, severity, state of consciousness)
  • history of head/neck surgery
  • lumps/swelling in neck
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17
Q

history of HEENT

A
  • vision changes
  • diplopia
  • hearing (earache, tinnitus, hearing loss)
  • vertigo
  • epistaxis
  • sore throat; hoarseness
  • swollen glands
  • goiter
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18
Q

for the physical exam, inspection is followed by?

A

palpation

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19
Q

inspection then palpation of head

A
  • normocephalic
  • symmetry
  • lumps
  • bumps
  • pain
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20
Q

inspection than palpation of temporal artery

A
  • pulse
  • temporal artery is a major artery located btw the eye and top of the ear
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21
Q

temporal arteritis

A
  • temporal artery is hard, thick, tender w/ inflammation
  • may lead to blindness
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22
Q

the strength of pulsation of the temporal artery may be ____ in older adults

A

decreased

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23
Q

inspection then palpation of face

A
  • symmetry
  • tenderness
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24
Q

temporomandibular joint (TMJ)

A
  • place index finger over front of each ear & ask pt to open mouth
  • palpate for swelling, tenderness, crepitation, pain, ROM
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25
Q

inspection then palpation of sinuses

A
  • frontal
  • maxillary
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26
Q

inspection then palpation of parotids

A
  • tender
  • enlarged
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27
Q

_____ can cause swelling of the parotid gland

A

viral infections (EX: mumps, flu)

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28
Q

what occurs w/ parotid gland enlargement?

A

asymmetry of face anterior to earlobes

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29
Q

what is associated w/ damage/trauma to facial nerve (7) or herpes simplex virus infection?

A

Bell’s palsy

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30
Q

Bell’s palsy

A
  • begins suddenly + reaches peak w/in 48 hrs
  • twitching, weakness, paralysis, drooping eyelid/corner of mouth, drooling, dry eye/mouth, decreased ability to taste, eye tearing, facial distortion
  • one-sided facial paralysis main
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31
Q

Parkinson’s disease

A
  • mask-like facial appearance
  • shuffling gait
  • rigid muscles
  • diminished reflexes
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32
Q

Neck has?

A
  • major muscles
  • blood vessels
  • trachea
  • thyroid glands
  • lymph nodes
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33
Q

abnormal findings of neck

A
  • nuchal rigidity
  • HA
  • elevated temp
  • ^associated w/ meningitis or encephalitis
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34
Q

where to find lymph nodes in head/neck?

A
  • preauricular
  • postauricular
  • tonsillar
  • occipital
  • submandibular
  • submental
  • superficial cervical
  • posterior cervical
  • deep cervical
  • supraclavicular
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35
Q

history for regional lymphatics

A
  • pain
  • lumps
  • discharge
  • rash
  • swelling
  • trauma
  • history of breast dz
  • surgery
  • self-care behaviors
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36
Q

what lymph nodes are usually not palpable?

A

axillary lymph nodes

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37
Q

axillary lymph nodes enlarge when?

A
  • local infection of breast , arm, hand
  • breast cancer metastases
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38
Q

abnormal lymph nodes w/ acute infection

A
  • enlarges
  • warm
  • tender
  • firm
  • moveable
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39
Q

abnormal lymph nodes w/ HIV

A
  • enlarged
  • firm
  • non-tender
  • mobile
  • occipital nodes often involved
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40
Q

abnormal lymph nodes w/ chronic infection

A

clumped nodes

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41
Q

abnormal lymph nodes w/ cancer

A
  • hard > 3 cm
  • unilateral
  • non-tender
  • fixed
  • matted
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42
Q

abnormal lymph nodes w/ Hodgkins

A
  • rubbery
  • discrete
  • appear gradually
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43
Q

abnormal lymph nodes w/ Virchow’s (sentinel node)

A
  • hard
  • non-tender
  • left supraclavicular node
  • highly suggestive of thoracic/abdominal cancer
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44
Q

in about 1/3 of population, _____ extends upward from the _____ or ________.

A
  • third lobe
  • Isthmus
  • one of the two lobes
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45
Q

how to palpate trachea and what are you inspecting + palpating for?

A
  • place finger in the sternal notch then feel each side of the notch + palpate tracheal rings
  • inspect and palpate for tracheal shift
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46
Q

abnormal inspection and palpation of thyroid

A

enlarges and/or tender to palpation

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47
Q

what is heard w/ auscultation of the thyroid w/ hyperthyroidism? why?

A
  • soft, blowing, swishing sound
  • increased blood flow thru thyroid arteries
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48
Q

if the thyroid can be palpated, the right lobe is often ____ than the left lobe normally

A

25% larger

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49
Q

sign of thyroiditis

A

enlarged, tender thyroid gland

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50
Q

what suggests a malignancy w/ the thyroid?

A

rapid enlargement of a single nodule

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51
Q

what indicates hyperthyroidism?

A

diffuse enlargement of the thyroid gland

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52
Q

what is not considered an abnormality in older adults?

A

increased in nodularity in the thyroid

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53
Q

after inspection + palpation, auscultating the thyroid, the pt should?

A

hold your breath to obscure any tracheal breath sounds during auscultation

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54
Q

during the trachea/thyroid exam, the neck should be?

A

slightly extended w/p being turned to any side

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55
Q

the pt does what during inspection/palpation of the thyroid gland, but not during auscultation?

A

swallows water

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56
Q

ask the patient to ________. observe the movement of the _____ cartilage and gland.

A
  • swallow a small sip of water
  • thyroid
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57
Q

the ____ and ____ cartilage move upward symmetrically as the client swallows.

A
  • thyroid
  • cricoid
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58
Q

thyroid gland symmetrical w/ _____. gland ______ with swallowing. ____ lobe may be up to ____ larger than the ___ lobe and tissue ____ and _____.

A
  • small lobes
  • rises freely
  • right
  • 25%
  • left
  • firm
  • pliable
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59
Q

what is considered abnormal for the thyroid gland?

A
  • asymmetric movement
  • generalized enlargement
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60
Q

_____ of a single thyroid nodule suggests ______ and must be evaluated further.

A
  • enlargement
  • malignancy
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61
Q

what suggests an enlarged thyroid gland, inflammation of lymph nodes, or a tumor?

A

swelling, enlarged masses or nodules

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62
Q

how to detect thyroid enlargement, nodules, masses, or tenderness?

A

palpating thyroid gland

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63
Q

when examining the thyroid gland, the nurse?

A
  • insepects for enlargement and asymmetry
  • auscultates for bruits
  • palpates for tumors, masses, size, tenderness
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64
Q

what does not provide meaningful data for the thyroid gland?

A

percussion

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65
Q

the nurse should auscultate the thyroid only if?

A

an enlarged thyroid gland is identified during inspection or palpation

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66
Q

hypothyroidism

A

a condition in which the body lacks sufficient thyroid hormone

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67
Q

hypothyroidism manifestations

A
  • edema around the eyes
  • dry, coarse, sparse hair
  • puffy, dull face
  • cold intolerance
  • muscle cramps
  • constipation
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68
Q

hyperthyroidism

A
  • overactive thyroid
  • thyroid gland produces too much of the hormone thyroxine
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69
Q

hyperthyroidism can ____ your body’s metabolism significantly, causing sudden weight _____, a ______ heartbeat (______), ______, and _____ or ________.

A
  • accelerate
  • loss
  • rapid or irregular (tachycardia)
  • sweating
  • nervousness
  • irritability
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70
Q

hyperthyroidism: lab data indicate that the pt’s ______ hormone levels are elevated. too much of the hormone ____ is secreted.

A
  • T4 and T3
  • thyroxine
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71
Q

the nurse auscultates an enlarged thyroid gland to search for?

A

presence of a bruit

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72
Q

use of tobacco and heavy alcohol consumption increases?

A

risk of cancer

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73
Q

gingivitis

A

red, swollen gums that bleed easily (early gum dz)

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74
Q

periodontitis

A

destruction of the gums w/ tooth loss (more advanced)

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75
Q

dental pain may occur with?

A
  • dental caries
  • abscesses
  • sensitive teeth
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76
Q

what is seen w/ aphthous stomatitis and herpes simplex? what are the other names for these 2 dzs?

A
  • canker sores (aphthous stomatitis)
  • cold sores (herpes simplex)
  • painful, recurrent ulcers in the mouth
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77
Q

what are warning signs of cancer?

A
  • mouth/tongue sores that do not heal
  • red/white patches that persist
  • lump/thickening
  • rough, crusty, or eroded areas
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78
Q

nose mouth throat history

A
  • hoarseness
  • medications (OTC nasal meds)
  • chronic alc + tobacco
  • dry mouth
  • check oral hygiene practices
  • cheilosis of lips
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79
Q

misuse of OTC nasal meds can?

A

irritate mucosa and cause rebound (common)

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80
Q

cheilosis of lips

A

scaling, painful fissures at the corner of lips

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81
Q

asking about proper use of nasal decongestants may explain?

A

recurrent sinus congestion + infection

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82
Q

nasal mucosa is normally?

A
  • dark pink
  • moist
  • free of exudate
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83
Q

the nasal septum is normally?

A
  • intact
  • free of ulcers, deviations, or perforations
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84
Q

turbinates are usually?

A
  • dark pink (redder than oral mucosa)
  • moist
  • lesions-free
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85
Q

the nose should normally have an absence of?

A

sniff

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86
Q

inspection: nose

A

check patency, mucosa nasal deviations

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87
Q

palpate: nose

A

discomfort

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88
Q

instructions for nose bleed

A

sit up, lean, forward, and pinch your nose

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89
Q

with a nose bleed, advise the person to ___, lean ____, and digitally compress the lower soft part of the nose for ______.

A
  • sit
  • forward
  • 15-20 minutes
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90
Q

inability to breath through both nostrils may indicate?

A
  • sinus congestion
  • obstruction
  • deviates septum
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91
Q

rhinorrhea and what it indicates

A
  • thin, watery, clear nasal drainage
  • chronic allergy
  • pt w/ past head injury: cerebrospinal fluid leak
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92
Q

yellow mucous drainage indicates?

A
  • cold
  • rhinitis
  • sinus infection
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93
Q

local causes of epistaxis

A
  • trauma
  • mucosal irritation
  • septal abnomrality
  • inflammatory dzs
  • tumors
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94
Q

systemic causes of epistaxis

A
  • blood dyscrasias
  • arteriosclerosis
  • hereditary hemorrhagic telangiectasia
  • idiopathic
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95
Q

common causes of epistaxis

A
  • local trauma (most)
  • facial trauma
  • foreign bodies
  • nasal/sinus infections
  • prolonged inhalation of dry air
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96
Q

four pairs of sinuses

A
  • frontal
  • maxillary
  • ethmoid
  • sphenoid
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97
Q

examine the sinuses through?

A

palpation and percussion

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98
Q

frontal or maxillary sinuses are tender to palpation in?

A
  • allergies
  • acute bacterial rhinosinusitis
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99
Q

large amount of exudate ____ upon palpation of _____.

A
  • crepitus
  • maxillary sinuses
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100
Q

what is seen in acute sinusitis (infection of the sinuses)?

A
  • pain
  • tenderness
  • swelling
  • pressure around the eyes
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101
Q

chronic sinusitis

A
  • sinus become inflamed and swollen
  • symptoms last 12 wks or longer even w/ treatment
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102
Q

palpate the maxillary sinuses by?

A

pressing w/ thumbs up on the maxillary sinuses

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103
Q

frontal + maxillary sinuses are tender upon percussion in pts w/?

A
  • allergies
  • sinus infection
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104
Q

percussion of the sinuses is not performed in an effort to?

A

gauge particular sounds

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105
Q

lips are normally?

A
  • smooth
  • moist
  • w/o lesions or swelling
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106
Q

jaws are normally?

A
  • aligned
  • no deviation seen w/ biting down
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107
Q

gums are normally?

A
  • pink
  • moist
  • firm
  • tight margins to the tooth
  • no lesions or masses
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108
Q

tongue should normally be?

A
  • pink
  • moist
  • moderate size
  • w/ papillae (little protuberances)
  • no lesions
  • no red color
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109
Q

what to use when holding pt’s tongue to each side?

A

square gauze pad

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110
Q

what should be even among cheeks and gums?

A

color + consistency of tissues

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111
Q

the dorsal surface of the tongue is normally?

A
  • roughened from papillae
  • thin, white coating may be present
  • ventral surface may show veins normally
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112
Q

indication of atrophic glossitis

A

smooth, glossy areas on tongue

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113
Q

inspect both sides of the tongue for?

A

cancer lesions

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114
Q

palpate what on the tongue for?

A
  • lesions
  • dryness
  • ulcers
  • nodules
  • for induration
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115
Q

what is seen on the tongue during dehydration?

A

deep tongue fissures

116
Q

a normal variation of the tongue in older adults is?

A

fissured, topographic-map-like tongue

117
Q

if white plaque on the tongue is removable, it is more likely a?

A

candida infection

118
Q

yeast infection of the tongue and what it requres

A
  • thick, white plaques on soft palate and tongue
  • require tx w/ meds
119
Q

is white plaque on the tongue cannot be removed, it is?

A

leukoplakia

120
Q

what on the tongue indicates cancer and should be referred?

A
  • leukoplakia
  • persistent lesions, ulcers, or nodules
121
Q

what increases the likelihood of cancer?

A

induration

122
Q

smokers may have what on their tongue?

A
  • yellow-brown coating
  • not leukoplakia
123
Q

throat: ask the client to say “aaah” and watch for the ____ and _____ to move bilaterally and symmetrically. what is this testing?

A
  • uvula
  • soft palate
  • testing CN IX & X
124
Q

what should be midline and rises with “ah” in the throat?

125
Q

what can cause deviation of the uvula?

A
  • damage to CN X
  • diphtheria
  • poliomyelitis
126
Q

when applying a tongue depressor, depress the tongue slightly _____ to avoid ____.

A
  • off-center
  • eliciting the gag response
127
Q

normal tonsils are?

A
  • involuted
  • granular in appearance
  • appear to have deep crypts (indentions)
  • pink mucosa
128
Q

what can develop in tonsil crypts? normal or abnormal?

A
  • plugs of white debris in tonsil crypts
  • normal
129
Q

bright red and swollen tonsils indicate?

130
Q

white membrane (exudate) covering tonsils can accompany?

A
  • infectious mono
  • leukemia
  • diphtheria
131
Q

1+ tonsils size

132
Q

2+ tonsils size

A

half way btw tonsillar pillars + uvula

133
Q

3+ tonsils size

A

touching the uvula

134
Q

4+ tonsils size

A

touching one another

135
Q

eyes - subjective data

A
  • vision-floaters
  • halos or scotoma
  • partial/complete loss of vision
  • photophobia, night blindness
  • pain, foreign body
  • strabismus (squint), diplopia
  • redness, swelling
  • discharge
  • hx. eye probs
  • glaucoma
  • wear glasses/contacts/corrective surgery
  • eye exam - when? (freq)
136
Q

vision-floaters is seen in?

A
  • myopia
  • over age 40
137
Q

halos or scotoma is seen in?

A

blind spot slightly w/ diminished peripheral vision

138
Q

glaucoma

A

halos around light

139
Q

eye - objective data

A
  • eye exam (shape, color, size)
  • inspect conjunctiva + sclera
  • visual acuity
  • pupillary light reflex
  • visual fields (confrontation)
  • extra-ocular movement
140
Q

the sclera and palpebral conjunctive should be?

A
  • sclera - white
  • palpebral conjunctiva - pink
141
Q

unless the conjunctiva is diseased, only visualizing sclera + palpebral vascular bed through the?

A

translucent conjunctiva

142
Q

how to better visualize sclera + palpebral conjunctivae

A

gently pull lower eyelid downward + ask the patient to look upward

143
Q

the sclera can appear ____ in pts w/ liver dz.

144
Q

in pts w/ conjunctivitis, the conjunctiva can become?

A

pinkish-red

145
Q

the iris should be?

A

round w/ an even distribution of color

146
Q

when shining penlight into eye, the lens should be ____ what indicates cataracts?

A
  • transparent
  • cloudly lens
147
Q

visual acuity tests?

A

cranial nerve II

148
Q

how to test visual acuity

A
  • Snellen chart
  • 20 ft away from chart - one eye at a time
  • covers one eye w/ an opaque card
  • reads each line of letters until he/she can no longer distinguish them (lowest line possible)
149
Q

normal acuity

150
Q

Near vision uses what cards?

A

Rosenbaum cards

151
Q

how far away should the Rosenbaum card be to test near vision?

A

about 14 in away

152
Q

what line do pts read to w/ the Rosenbaum card?

A

lowest possible line

153
Q

how does the pt read the Rosenbaum cards (the set up)?

A

reads letters w/ glasses if needed

154
Q

normal near vision means?

A
  • 14/14
  • person can read what the normal eye can read from a distance of 14 in
155
Q

record the pt’s visual acuity as a fraction. the numerator indicates _________ and the denominator indicates ___________.

A
  • distance pt is from the chart
  • distance at which a normal eye can read the line on the chart
156
Q

20/25 visual acuity means

A

client can read at 20 ft what the avg pt can read at 25 ft

157
Q

visual acuity: the large the denominator, the _____ the vision.

158
Q

legally blind

A

vision that cannot be corrected to better than 20/200

159
Q

normal pupillary response

A

constriction of the pupils and convergence of the eyes when focusing on a near object (accommodation and convergence)

160
Q

pupillary size (bright light and dark light)

A
  • 3-5 mm in bright light
  • 4-8 mm in dark light
161
Q

pupillary response to light is what cranial nerve?

162
Q

how to test pupillary response

A
  • advance the light from pt’s side
  • shine light from lateral side of eye or from beneath to help ensure client dosn’t accommodate pupils for near vision
163
Q

direct pupillary response

A

constriction of the pupil w/ light

164
Q

consensual pupillary response

A

simultaneous constriction of other pupil

165
Q

when testing for the consensual response, what should the nurse do?

A

place a hand or another barrier to light btw person’s eyes (avoid inaccurate finding)

166
Q

when light is shone in one eye, the eye will ______ and the opposite (_______) eye will also ______.

A
  • constrict
  • consensual
  • constrict
167
Q

direct reflex of eye

A

shining light in one eye w/ resulting constriction of that rye

168
Q

optic chiasm

A

point where the optic nerves from each eyeball cross

169
Q

when does accommodation occur?

A

client moves the focus of vision from distant point to a near object - cause pupils to constrict

170
Q

convergence

A

pupils constrict; both move to center to focus on object

171
Q

accommodation (distant + near)

A
  • distance: dilates
  • near: constricts
172
Q

PERRLA

A

pupils equal, round reactive to light & accommodation

173
Q

visual fields (confrontation) tests?

A

assess peripheral vision w/ examiner’s vision

174
Q

visual fields (confrontation) direction

A
  • equal height; 2 ft away
  • cover one eye; examiner covers opposite eye
  • look directly at each other w/ uncovered eyes
  • fully extend left arm at midline + slowly move 1 finger (or pencil) upward from below until pt sees finger/pencil (inferior)
  • test remaining 3 visual fields of pt’s right eye (superior, temporal, nasal)
  • repeat test for opposite eye
175
Q

eyes EOM

A
  • extraocular motion (EOM)
  • assess ability of eyes to move through 6 cardinal positions of gaze (CN III, IV, VI)
  • note conjugate movement, nystagmus
176
Q

normal EOM

A
  • steady head
  • eyes follow finger movement thru 6 positions in clockwise direction
177
Q

CN III, IV, VI

A
  • III: oculomotor
  • IV: trochlear
  • VI: abducens
178
Q

failure of eyes to follow movement symmetrically in any/all directions for EOM indicates?

A
  • weakness in one or more extraocular muscles or dysfxn of CN that innervates particular muscle
179
Q

Nystagmus

A

oscillating (shaking) movement of eye

180
Q

nystagmus may be associated w/ ?

A
  • inner ear dz
  • multiple sclerosis
  • brain lesions
  • narcotics use
181
Q

when is nystagmus considered normal?

A

a couple of oscillating movements of nystagmus at extreme lateral gaze

182
Q

corneal light reflex test is also called?

A

Hirschberg test

183
Q

corneal light reflex tests and assess?

A
  • test balance of extraocular muscles
  • assesses parallel alignment of eyes
184
Q

corneal light reflex test: asymmetric position of the light reflex equals?

A

deviated alignment of eyes

185
Q

strabismus/tropia

A
  • constant misalignment of the eye axis
  • strabismus defined according to direction toward which the eye drifts
186
Q

esotropia

A

eyes turns inward

187
Q

exotropia

A

eye turns outward

188
Q

cover-uncover test can be used to screen for?

A

strabismus, EOM

189
Q

cover-uncover test: pt is instructed to?

A

cover one eye; nurse observes uncovered eye movement as it focuses on an object

190
Q

right esotropia

A
  • right eye usually in with left eye uncovered
  • left eye covered, right eye moves outward to pick up fixation
191
Q

an abnormal finding during the cover-uncover test is strabismus, where?

A

one eye deviates to the middle due to weakened extraocular muscles

192
Q

tropia

A

direction of the strabismus (or misalignment)

193
Q

hypertropia

A

eye deviated upward

194
Q

hypotropia

A

eye deviated downward

195
Q

how to conduct cornea light reflex test/Hirschberg test

A

(1) use light source like penlight
(2) instruct pt to focus gaze on light source
(3) at 2 ft distance: shine light source equally into pt’s eyes at the midline
(4) observe reflection of light off cornea: should appear as pin-point white light near center of same pupil spot in each eye

196
Q

if there is normal alignment during the cornea light reflex/Hirschberg test, then?

A

reflection will appear in the same position in each pupil

197
Q

if there is a misalignment of the eyes during the cornea light reflex/Hirschberg test, then?

A

location of the corneal reflex will appear asymmetric + “off center” of pupil in deviating eye

198
Q

misalignment, Hirshberg’s: the relative difference in the position of the reflex will be?

A

in the opposite direction as the eye deviation

199
Q

Hirschberg test is useful for strabismus testing in?

A
  • newborns
  • young children
  • pts w/ poor vision
  • pts that cannot fixate/track well
  • any situation where full motility eval not feasible
200
Q

esotropia in Hirschberg test

A

light reflex will appear outwardly displaced from center of pupil

201
Q

hypertropia in Hirshberg test

A

light reflex will appear inferiorly displaced from the center of pupil

202
Q

objective findings in exophthalmos

A
  • apparent eye protrusion
  • lids don’t reach iris
  • measurement of degree of exophthalmos performed using exophthalmometer
203
Q

objective findings in strabismus

A
  • eye will not move in direction controlled by affected muscle
  • abnormal cover-uncover result
204
Q

objective findings in cataracts

A
  • cloudly lens
  • may be obvious w/o equipment
205
Q

objective findings in glaucoma

A
  • optic nerve damage (clearly seen during dilated eye exam)
  • characteristic of cupping of optic nerve
  • visual field test show peripheral vision loss
206
Q

an eye that fells firm/resistant to palpation could indicate?

A

glaucoma or tumor

207
Q

anisocoria

A

difference in size of pupils (brain injury)

208
Q

ptosis

A

dropping upper lid

209
Q

miosis

A

constricted (pinpoint) pupils (narcotic drugs or brain damage)

210
Q

mydriasis

A

dilated pupils (CNS injury, circulatory collapse, deep anesthesia)

211
Q

monicular blindness can be detected when light directed to blind eye results in?

A

no response in either pupil bc optic neuropathy/ocular disorder produce acute visual loss

212
Q

light is directed to the unaffected eye in a pt w/ monicular blindness results in?

A

both pupils constricting

213
Q

arcus senilus

A

grey-white arc/circle caused by lipid deposition around limbus of older adult

214
Q

what is the effect of arcus senilus on vision?

215
Q

arcus senilus is possibly r/t?

A

cholesterol

216
Q

xanthelasma

A
  • benign lesions usually on eyelids
  • soft, raised yellow plaques occurring on lids at inner canthus
  • frequently seen in females
217
Q

corneal abrasion

A
  • one of the most common eye injuries
  • pain, erythema, tearing, photophobia
218
Q

conjunctivitis

A
  • clear/purulent discharge
  • usually viral but can be bacterial
  • commonly tx w/ antibx
219
Q

subjective data of the ear

A
  • earaches
  • drainage
  • loss of hearing
  • tinnitus
  • vertigo
  • env noise exposure
  • bloody or clear watery drainage
220
Q

earaches can come from?

A
  • ear infections
  • cerumen blockage
  • sinus infections
  • teeth/gum probs
221
Q

drainage of the ear can also be called and can come from?

A
  • otorrhea
  • infection
222
Q

potential causes of tinnitus

A
  • excessive earwax buildup
  • high BP
  • certain ototoxic meds
  • loud noises
223
Q

examples of ototoxic medications that can cause tinnitus

A
  • streptomycin
  • gentamicin
  • kanamycin
  • neomycin
  • ethacrynic acid
  • durosemide
  • indomethacin
  • aspirin
224
Q

vertigo causes?

A
  • dizziness
  • spinning
225
Q

vertigo stems from?

A

inner ear/labyrinthitis/vestibular nerve prob (vestibular neuritis)

226
Q

bloody or clear watery drainage is likely to be _________ and can indicate?

A
  • cerebrospinal fluid
  • basal skull fracture after a srs accident or head injury
227
Q

tympanic membrane

A
  • pearly gray, shiny, translucent
  • no bulging or retraction
  • slightly concave, smooth, intact
228
Q

normal findings of the tympanic membrane using the otoscope

A
  • cone-shaped reflection
  • 5 o’clock in right ear
  • 7 o’clock in left ear
229
Q

dense, white patches and scars on the tympanic membrane are?

A

sequelae of repeated ear infections in childhood or earlier

230
Q

bluish or dark red color to the tympanic membrane would suggest?

A

skull trauma

231
Q

what can prevent the nurse from viewing the tympanic membrane?

A

impacted cerumen

232
Q

what can suggest acute otitis media?

A
  • red, bulging eardrum
  • distorted, diminished, or absent light reflex
233
Q

the ear is lined with glands that secrete?

234
Q

type of cerumen found in Caucasians and African Americans

A

wet, honey brown

235
Q

type of cerumen found in East Asians and American Indians

A

dry, flakey white

236
Q

cerumen’s purpose

A

lubricate, waterproof, and clean the external auditory canal

237
Q

cerumen is not needed to? too much cerumen can?

A
  • transmit sound through the auditory canal
  • impair hearing
238
Q

cerumen is also _____ and traps ________. wet, honey-colored cerumen is ________.

A
  • antibacterial
  • foreign bodies
  • not a sign of infection
239
Q

gross examination of the external ear and middle requires an _______. how should you position an adult’s ear for the examination?

A
  • otoscope
  • pull auricle of ear up and back
240
Q

whisper test

A
  • gross assessment for high-frequency sounds
  • whisper two-syllable words like popcorn or football
241
Q

whisper test is associated with what CN?

242
Q

Presbycusis

A

high-frequency hearing loss that occurs with aging

243
Q

conductive hearing deficit

A

cerumen impaction + otitis media most common cause

244
Q

flaking wax in the external ear is/is not pathologic?

245
Q

what happens when the ear’s labyrinth becomes inflamed?

A

feeds the wrong info to brain, causing:
- staggering gait
- vertigo

246
Q

vertigo

A

strong, spinning, whirling sensation

247
Q

in general, vertigo is from?

A
  • labyrinth of the ear
  • vestibular nerve issue
248
Q

perform the _____ test if diminished or lost hearing in one ear

249
Q

the Weber test detect _____ conductive hearing loss (______ hearing loss) and _______ sensorineural hearing loss (_____ hearing loss)

A
  • unilateral
  • middle ear
  • unilateral
  • inner ear
250
Q

weber test: conductive loss will cause the sound to be heard best in?

A
  • abnormal ear
  • pt hears the sound in poor ear (bone vibration)
251
Q

weber test: sensorineural loss will cause the sound to be heard best in?

A
  • normal ear
  • where you can listen to sound best in air conduction only
252
Q

weber test: in sensorineural loss, the _______ of sound due to nerve damage in bad ear makes the sound seem louder in?

A
  • limited perception
  • the unaffected ear
253
Q

Rinne test is used to determine?

A

the cause of the hearing loss

254
Q

Rinne test: first, tuning fork on the _______. after the prongs are moved to the front of ____.

A
  • mastoid process
  • external auditory canal
255
Q

Normal Rinne test

A

AC (air conduction) twice as long as BC (bone conduction)

256
Q

sensorineural hearing loss Rinne test

257
Q

conductive hearing loss Rinne test

258
Q

why is BC ≥ AC in Rinne test with conductive hearing loss?

A

air conduction thru the external/middle ear is impaired so vibrations thru bone bypass the impairment to reach the cochlea

259
Q

why is AC > BC in Rinne test with sensorineural hearing loss?

A
  • both are decreased
  • inner ear/cochlear nerve less able to transmit impulses regardless of how vibrations reach the cochlea
260
Q

weber test: sensorineural hearing loss may be caused by what?

A
  • presbycusis
  • gradual nerve degeneration that occurs w/ aging + by ototoxic drugs (affect hair cells in cochlea)
261
Q

purulent otorrhea

A
  • ear drainage
  • probable otitis externa or perforated tympanic membrane
262
Q

_______ drainage suggests an infection of the external ear (_____) w/ _______ of pinna & ear canal and _______ regional lymph nodes

A
  • purulent, bloody
  • external otitis
  • redness, swelling
  • itching, fever, enlarged tender
263
Q

_______ associated with ____ and a _____ sensation is characteristic of otitis media with perforation of the tympanic membrane associated with ________.

A
  • purulent drainage
  • pain
  • popping
  • bloody, clear, or resembles pus
264
Q

in otitis externa, the patient experiences pain when?

A

the pinna and the tragus are moved

265
Q

otitis externa

A

enlarged superficial cervical nodes

266
Q

otitis externa is also associated w/ ______ and is nicknamed?

A
  • submersion in water
  • swimmer’s ear
267
Q

older adult’s thyroid may feel more _____ bc of _____ changes that occur w/ aging.

A
  • nodular/irregular
  • fibrotic
268
Q

the thyroid of an older adult may also be felt ____ in the neck because of age-related ______.

A
  • lower
  • structural changes
269
Q

age-related changes: ____ visual acuity, visual fields; light/dark adaptation

270
Q

age-related changes: ___ sensitivity to glare

271
Q

age-related changes: presbyopia

A

loss of near-focusing ability

272
Q

age-related changes:__ incidence of glaucoma

273
Q

age-related changes: ___ depth perception

274
Q

age-related changes: less able to differentiate?

A

blues, greens, violets

275
Q

age-related changes: __ eye dryness + irritation

276
Q

increasing age, esp over 75, risk factors for?

277
Q

_____ are normal over 40 years of age.

A

vision-floaters

278
Q

age-related changes: __ hearing acuity, esp to hear _____

A
  • decreased
  • consonants
279
Q

age-related changes: loss of hearing from ______ and ___

A
  • high frequency
  • presbycusis
280
Q

otosclerosis

A
  • progressive conductive hearing loss in young adults btw 20-40 yo
  • gradual bone formation causes stapes footplate to become fixed in oval window, impeding transmission of sound + causing progressive deafness
281
Q

age-related changes: difficulty hearing, esp w/ ?

A
  • background noise
  • rapid speech
282
Q

age-related changes: __ cerumen, cerumen _____ so ____ cerumen impaction

A
  • increased
  • drier
  • increased
283
Q

age-related changes: __ olfactory nerve fibers = ___ ability to smell noxious odors

284
Q

age-related changes: ____ food intake

285
Q

age-related changes: altered ability to taste? what remains unchanged?

A
  • altered sweet and salty
  • bitter and sour unchanged
286
Q

age-related changes: tongue looks ____ because of?

A
  • smoother
  • papillary atrophy
287
Q

age-related changes: teeth are slightly ____ and appear ____ because of?

A
  • yellowed
  • longer
  • recession of gingival margins

health assess (3 decks)

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